Crestmoor Care Center: Infection Control Violations - CO

The incident at Crestmoor Care Center was documented during a federal inspection in February 2025 that found widespread infection control failures, expired medications dating back to December 2023, and food safety violations affecting many residents.

Housekeeper #1 was observed on February 5 cleaning room after room while repeatedly contaminating surfaces. He changed gloves six times during a single room cleaning but never performed hand hygiene between glove changes. After scraping feces from the bathroom floor with his chisel, he wiped it on the mop head several times, then wiped it on his pants before returning it to his pocket.

The same chisel was later used to scrape the sink surface, bedside table, and multiple floor areas without any disinfection. He failed to clean high-touch surfaces including call lights, remotes, door handles, and light switches.

A second housekeeper observed the following day showed similar infection control lapses. Housekeeper #2 moved between rooms without performing hand hygiene between glove changes and used the same mop pad to clean both sides of shared rooms, pushing debris including cotton gauze and rubber bands from one side to the other.

Neither housekeeper disinfected toilet brushes after use, despite facility policy requiring sanitization between rooms.

The Environmental Services Director told inspectors housekeepers should sanitize the toilet scrub brush between each room and use hand sanitizer after removing dirty gloves. When asked about the chisel use, he said he assumed the housekeeper disinfected it between uses.

Resident #52 developed a urinary tract infection in January 2025 while receiving catheter care that violated basic infection control protocols. The 83-year-old had an indwelling catheter since returning from the hospital in October 2024, but the facility failed to establish proper care procedures for nearly four months.

Licensed Practical Nurse #1 was observed providing catheter care on February 6 without wearing a gown, despite facility requirements for enhanced barrier precautions. She used the same washcloth to wipe the resident's perineum and catheter tubing, then wiped the catheter from the bag toward the perineum — the opposite of proper technique.

The Director of Nursing admitted the physician's order for catheter care wasn't added until February 6, during the inspection. "The admission nurse missed the order for catheter care and the mistake just carried on," she said. No catheter care plan existed in the resident's comprehensive care plan.

Staff demonstrated confusion about proper catheter care procedures. Certified Nurse Aide #5 said CNAs only wore gloves when emptying catheter bags "if the resident did not have anything infectious." Another aide said staff only needed gloves when specifically working with catheters, not during other high-contact care.

The facility's Enhanced Barrier Precautions policy requires gown and glove use for residents with indwelling devices during high-contact care activities including dressing, bathing, transferring, and device care. But Resident #52's room had no EBP sign on the door and no PPE supplies available.

Registered Nurse #2 provided feeding tube care for Resident #284, who had an EBP sign posted, but entered the room wearing only gloves. When asked about the gown requirement, he said he "was not aware that a gown needed to be used for residents on EBP."

The same nurse was observed performing tracheostomy suctioning using contaminated technique. He laid sterile equipment on an uncleaned bedside table, put on gloves without hand hygiene, then touched non-sterile surfaces including the privacy curtain, bed controls, and his pen. When the tracheostomy tubing fell to the floor, he picked it up with his supposedly sterile hand.

"He then said that he thought it was clean enough," inspectors noted after watching him rinse a tracheostomy mask with tap water and dry it with paper towels.

Medication storage violations were found in two of four medication carts inspected. The south hall cart contained a COVID-19 testing reagent that expired in December 2023 — more than two years past expiration. Other expired items included vitamin supplements, calcium acetate, naproxen sodium, and bisacodyl suppositories.

Five insulin pens for four different residents lacked required opening dates. Insulin can be stored unrefrigerated for up to 28 days after opening, but without date labels, staff cannot determine safety.

Multiple loose pills were scattered in three drawers of the medication cart. The Director of Nursing said there should not be any loose pills in the carts and acknowledged they were falling behind on medication disposal because only two staff members performed the task.

Food safety problems extended throughout the facility. The north hall nourishment refrigerator operated at 56 degrees Fahrenheit — 15 degrees above the safe temperature limit. Temperature logs showed it had run between 56-58 degrees for six consecutive days with no corrective action documented.

Inside the overheated refrigerator, inspectors found an open container of unlabeled applesauce and a thawed nutritional dessert cup that should have been stored frozen. The dessert's instructions specified it must be used within five days of thawing in proper refrigeration.

The activities room refrigerator contained multiple expired condiments, including mustard that expired in 2023. The Activities Director discarded the expired items during the inspection.

A dietary aide preparing lunch was observed using the same gloves to handle hamburger buns, lettuce, onion slices, and potato chips from multiple bags — violating requirements that single-use gloves be used for only one task with ready-to-eat foods.

The Dietary Manager acknowledged ready-to-eat foods should be handled with clean gloves used only for one task, and that cold food needed to be kept below 41 degrees Fahrenheit.

Personal refrigerators in resident rooms also operated above safe temperatures. Three resident refrigerators recorded temperatures of 42-44 degrees Fahrenheit with gaps in temperature monitoring. Staff failed to take corrective action despite temperature logs showing the violations.

Resident #13 said facility maintenance staff checked his refrigerator temperature "but did not do it every day" and "no one came in and checked through his refrigerator to see if things were expired."

The Environmental Services Director said housekeeping staff were responsible for checking resident refrigerator temperatures daily, but called it "a grey area which department was responsible for the refrigerators."

Vital signs equipment was observed being carried between residents without disinfection. Certified Nurse Aide #7 used the same blood pressure cuff, pulse oximeter, and thermometer on multiple residents during a 90-minute period without cleaning between uses.

The Clinical Consultant acknowledged CNAs were responsible for cleaning equipment between residents and should use sanitizing wipes on vital sign machines between each use.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Crestmoor Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.

Additional Resources

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